Eur Radiol (2008) 18: 1307–1318

DOI 10.1007/s00330-008-0863-7 NEWS FROM EU SOBI

R. M. Mann
C. K. Kuhl
Breast MRI: guidelines from the European
K. Kinkel
C. Boetes
Society of Breast Imaging

Received: 4 October 2007 K. Kinkel MRI should only be offered by

Revised: 10 December 2007
Accepted: 1 January 2008
Published online: 4 April 2008
# The Author(s) 2008
On behalf of EUSOBI Committee (see:
http://www.eusobi.org).
C. Boetes . R. M. Mann (*)
Department of Radiology,
Radboud University Nijmegen
Medical Centre,
Geert Grooteplein 10,
P.O. Box 9101 (667), 6500 HB
Nijmegen, The Netherlands
e-mail: r.mann@rad.umcn.nl
Tel.: +31-24-3614546
Fax: +31-24-3540866
e-mail: c.boetes@rad.umcn.nl
C. K. Kuhl
Department of Radiology,
University of Bonn,
Sigmund-Freud-Strasse 25,
53127 Bonn, Germany
e-mail: kuhl@uni-bonn.de
Department of Radiology,
Clinique des Grangettes,
7, chemin des Grangettes,
1224 Genève, Switzerland
e-mail: Karen.Kinkel@grangettes.ch
Abstract The aim of breast MRI is to
obtain a reliable evaluation of any
lesion within the breast. It is currently
always used as an adjunct to the
standard diagnostic procedures of the
breast, i.e., clinical examination,
mammography and ultrasound.
Whereas the sensitivity of breast MRI
is usually very high, specificity—as in
all breast imaging modalities—
depends on many factors such as
reader expertise, use of adequate
techniques and composition of the
patient cohorts. Since breast MRI will
always yield MR-only visible ques-
tionable lesions that require an MR-
guided intervention for clarification,
institutions that can also offer a MRI-
guided breast biopsy or that are in
close contact with a site that can
perform this type of biopsy for them.
Radiologists involved in breast imag-
ing should ensure that they have a
thorough knowledge of the MRI
techniques that are necessary for
breast imaging, that they know how to
evaluate a breast MRI using the ACR
BI-RADS MRI lexicon, and most
important, when to perform breast
MRI. This manuscript provides
guidelines on the current best practice
for the use of breast MRI, and the
methods to be used, from the Euro-
pean Society of Breast Imaging
(EUSOBI).
Keywords Breast . Breast
neoplasms . Magnetic resonance
imaging . Practice guideline

Introduction treatment and the evaluation of residual disease after-

The overall aim of breast imaging can be summarized
under several general headings. First, it is performed in
symptomatic women to exclude breast cancer or other
disease that requires immediate treatment. In this
respect, it should provide a definitive diagnosis or
exclude the presence of a harmful abnormality. Second,
in patients with known malignancies, imaging helps in
the preoperative staging and subsequent choice of
appropriate therapy, either surgical or medical. Third,
in patients with known malignancies that are initially
treated medically with neoadjuvant chemotherapy, im-
aging is helpful in the assessment of response to
wards. Fourth, imaging is performed in asymptomatic
women to detect breast cancer in its early stages, when
it can be better treated, and in this respect imaging
increases the prognosis and survival of breast cancer
patients. Last, imaging may be used to evaluate foreign
bodies within the breast, such as the location of clips
and markers or whether breast prostheses are intact.
Magnetic resonance imaging of the breast can be used to
pursue any of the above-mentioned goals.
The aim of this paper is to provide guidelines for the
performance and use of breast MRI, with respect to both
the technical aspects of this procedure and the current
indications.
1308
Technical aspects
Patient handling
MRI of the breast is a study that requires the administration
of a gadolinium-containing contrast agent during the study
[1, 2]. Early studies have shown that breast MRI without
contrast agent is not of diagnostic value [3, 4].
The uptake of contrast medium in breast tissue in
premenopausal women is also dependent on the phase of
the menstrual cycle. It is essential to perform breast MRI in
the correct phase of the cycle as enhancing normal breast
tissue may otherwise complicate the interpretation of the
study. The optimal time in pre-menopausal women to
perform a breast MRI is between the 5th and 12th day after
the start of the menstrual cycle [5–7].
Placement of an intravenous cathether should be done
before positioning the patient on the MR table. A long IV
line avoids table and patient movement before the injec-
tion. The contrast agent should preferably be given by a
power injector.
It is important to position the patient as comfortably as
possible in order to avoid motion artifacts.
A dedicated bilateral breast coil is mandatory for this
investigation, and the patient should be placed in the prone
position with both breasts hanging in the coil loops. The
breasts may be supported to further reduce motion artifacts,
but should not be compressed.
The position of the breast should be checked before the
start of the examination, both breasts must be placed as
deeply as possible in the coils with the nipples pointing
down. A larger breast coverage is usually obtained by
placing both arms at the side of the body and not above the
patient’s head.
Virtually any MRI scanner can be used to perform
contrast-enhanced breast MRI, as long as the system allows
image acquisition at a sufficient spatial and temporal
resolution (see below). However, scanning protocols need
to be adapted to the scanners used, also because the
relaxivity of the most commonly used contrast agents
decreases at higher field strengths [8, 9]. Breast MRI at low
and midfield strength (0.2 T, 0.5 T) depends heavily on
parallel imaging to obtain a sufficient resolution. As this
further decreases the signal-to-noise ratio (SNR), this is not
optimal. In practice, most studies that employed low or
midfield scanners did not obtain a sufficient spatial
resolution [10, 11]. An increasing field strength (1.5 T, 3
T) allows a higher spatial resolution at a similar temporal
resolution and consequently may increase diagnostic
confidence [12]. A disadvantage is that, at higher field
strengths (e.g. 3 T), inhomogeneity in the B1 field may
cause reduced signal in parts of the image and thus less
contrast enhancement, which in turn may cause false-
negative image interpretation. Two-dimensional acquisi-
tions are particularly sensitive to this effect and are
therefore discouraged at 3 T [13].
Sequences
The conventional breast MRI investigation begins precon-
trast with either T2- or T1-weighted images.
The signal from the body coil can be used to evaluate the
position and anatomy of the breasts. Furthermore, both
axillae, the supraclavicular fossae, the chest wall and
anterior mediastinum can be checked (e.g., for enlarged
lymph nodes). However, this is not the purpose of a breast
MRI, and this evaluation may also be omitted as there is no
evidence of its diagnostic value.
Afterwards the signal from the dedicated double breast
coil should be used.
T2-weighted fast spin echo images can be performed as a
start.
In the T2-weighted images water-containing lesions or
edematous lesions have an intense signal, and in this
sequence small cysts and myxoid fibroadenomas are very
well identified.
In most cases cancer does not yield a high signal on T2-
weighted images; thus, these sequences can be useful in the
differentiation between benign and malignant lesions.
However, as most of these lesions can also be identified
on T1-weighted images, there is no evidence as yet of added
value of T2-weighted sequences in breast MRI [14, 15].
The most commonly used sequence in breast MRI is a
T1-weighted, dynamic contrast enhanced acquisition. The
sequence is called ‘dynamic’ because it is first performed
before contrast administration and is repeated multiple
times after contrast administration.
A T1-weighted 3D or 2D (multi-slice) spoiled gradient
echo pulse sequence is obtained before contrast injection
and then repeated as rapidly as possible for 5 to 7 min after
a rapid intravenous bolus of a Gd-containing contrast
agent. A 3D pulse sequence offers a stronger T1 contrast
and enables thinner slices than 2D; in turn, a 2D sequence
suffers less from motion and pulsation artifacts. Both
sequences can be performed with and without fat-
suppresion [16, 17].
The choice of the image orientation is important. For
bilateral dynamic breast MRI, axial or coronal orientations
are most frequently used. Coronal imaging has advantages
in that it can reduce heart pulsation artifacts, but it is more
susceptible to respirational motion and also to flow artifacts
because vessels tend to travel perpendicular to the slice-
encoding direction. Although bilateral sagittal imaging is
possible today, it requires about double the number of
slices required for the other orientations. As this hampers
the spatio-temporal resolution, such an orientation is
currently not feasible.
The optimal dose of the contrast medium is unknown
and also depends on the contrast agent used. In literature,
applied doses range roughly from 0.05 to 0.2 mmol/kg.
One study showed some benefit of 0.16 mmol/kg
gadopentetate dimeglumine over 0.1 mmol/kg [18]. How-
ever, a more recent evaluation did not find any improve-

ment in diagnostic accuracy using 0.2 mmol/kg gadobenate
dimeglumine over 0.1 mmol/kg of the same agent [19].
Consequently, a dose of 0.1 mmol/kg is probably
sufficient.
Peak enhancement in the case of breast cancer occurs
within the first 2 min after the injection of contrast medium.
Therefore, relatively short data acquisition times, in the
order of 60–120 s per volume acquisition, are necessary.
This allows sampling of the time course of signal
enhancement after contrast injection, which is useful
because the highly vascularized tumor of the breast
shows a faster contrast uptake than the surrounding tissue.
More importantly, it enables a detailed analysis of
morphologic details, because only in the very early post-
contrast phase, the contrast between the cancer and the
adjacent fibroglandular tissue is optimal. Tumors may lose
signal (a phenomenon referred to as “wash out”) as early as
2–3 min after contrast material injection, whereas the
adjacent fibroglandular tissue can still exhibit substantial
enhancement, resulting in little contrast between the cancer
and the fibroglandular tissue. Long acquisition times will
be associated with the risk of not resolving fine details of
margins and internal architecture; this could have key
importance for the differential diagnosis, and may even run
the risk of missing cancers altogether because they are
masked by adjacent breast tissue.
A dynamic sequence demands at least three time points
to be measured, that is, one before the administration of
contrast medium, one approximately 2 min later to capture
the peak and one in the late phase to evaluate whether a
lesion continues to enhance, shows a plateau or shows early
wash-out of the contrast agent (decrease of signal intensity)
[20]. It is thus recommended to perform at least two
measurements after the contrast medium has been given,
but the optimal number of repetitions is unknown.
However, the temporal resolution should not compromise
the spatial resolution. It was shown that an increase in spatial
resolution results in higher diagnostic confidence even when
the temporal resolution is slightly sacrificed. [21].
The final spatial resolution of the images depends on
different factors, especially the size of the imaging
volume, defined by the field of view (FOV), the slice
thickness and the acquisition matrix. Breast MRI
should be capable of detecting all lesions larger than
or equal to 5 mm. Therefore, the voxel size should be
under 2.5 mm in any direction. Preferably, the in-plane
resolution should be substantially higher as morpholo-
gic features needed for lesion characterization, such as
margin appearance, can only be evaluated when the
resolution is sufficiently high. Therefore, the in-plane
resolution should be at least 1 mm−1 , in other words:
pixel size (FOV/matrix) should not be greater than
1×1 mm, which requires a matrix of at least 300×300
in a 300-mm FOV.
Assessment of lesion morphology can be performed
directly on the enhanced fat-suppressed images. However,
1309
as residual fat-signal (hyperintense at T1-weighted images)
may cause difficulties in interpretation, the calculation of
subtraction images from the pre- and post-contrast series is
recommended [22, 23].
Subtraction suppresses the signal from bright fat because
fatty tissue hardly enhances. When subtraction is per-
formed, fat suppression in the acquisition is not needed and
is even discouraged, because in the large fields of view that
are usually required for axial and coronal imaging,
homogenous fat suppression is difficult to obtain. This
can be problematic since fat and water resonance
frequencies are relatively close at 1.5 T—which implies
that with less-than-optimal B0 homogeneity across the
field of view, water (rather than fat) suppression can occur.
Moreover, fat-suppression increases the noise in the image
and usually also compromises spatio-temoral resolution.
Evaluation
Use of both detailed morphological information provided
by high spatial resolution images and kinetic information
(curve type) provided by at least two repetitions of the high
spatial resolution sequence represents the latest trend in
acquisition protocols and image interpretation to take into
account the increasing importance of detailed morpholog-
ical information without losing identification of washout
enhancement curve types [24].
For the diagnostic interpretation the ACR breast imaging
reporting and data system (BIRADS) for breast MRI
illustrates many of the morphological findings seen on
contrast-enhanced breast MRI. It also includes a lexicon
that should be used for uniform reporting of the features
seen on MRI [25].
Indications for breast MRI
Inconclusive findings in conventional imaging
Patients referred by their general practitioner or through a
nationwide screening program to secondary care are told
that there is a chance that they might have breast cancer. In
this situation imaging, with or without biopsy, should
exclude the presence of a malignancy sufficiently. The
sensitivity of breast MRI for the detection of cancer is
the greatest of all imaging techniques [26–28], and when
the findings of conventional imaging are inconclusive (i.e.,
BI-RADS 0), MRI can be used as a problem-solving
modality. In general, a negative breast MRI excludes
malignancy. Only in case of mammographic microcalcifi-
cations, MRI is unable to exclude cancer sufficiently, and
the decision to perform biopsy should be based on
mammographic findings in this specific situation [29].
1310
Preoperative staging
Breast tumors may be solitary, well-circumscribed masses
that are well recognized at mammography and/or sonog-
raphy. However, tumor size may be underestimated
severely by mammography and ultrasound, especially in
tumors larger than 2 cm [30, 31]. Tumor size of invasive
carcinomas on MRI correspond in general well to patho-
logic sizes [32, 33]. Unfortunately, MRI has a tendency to
overestimate the size of pure DCIS lesions [34]. Further-
more, in about 25% of the cases, the tumor is multifocal; in
other words, there are more invasive tumors in one
quadrant. Moreover, multicentricity, which means one or
more invasive foci more than 4 cm from the primary tumor,
is present in about 20% of all invasive malignancies.
Inadequate size estimation or failure to detect additional
foci of disease may thus result in positive resection margins
after surgery or early recurrent disease.
The sensitivity of breast MRI is, in the setting of
preoperative evaluation, close to 100% [26]. MRI is the
most reliable imaging technique to measure the tumor size
[35, 36], and it detects additional foci of the tumor in the
ipsilateral breast in 10–30% of patients [37–45]. Also the
presence of an intraductal component (EIC+) can be better
evaluated by MRI than with mammography [36, 46–48].
On MRI this may be seen as an area of contrast
enhancement with a dendritic configuration close to the
primary tumor. However, approximately 20% of the
additional foci detected by MRI are benign [43, 49].
Consequently, before large adjustments to the surgical
management are effectuated, histological analysis of MR-
detected additional foci should be performed.
Several studies have shown a change in surgical
management in about 20% to 30% of all patients under-
going preoperative MRI [26, 37, 39, 49]. Changes were
greatest in patients with tumor size greater than 4 cm [50],
lobular carcinoma [37] or breast density 4 [49].
However, it is so far unclear whether breast MRI
contributes to better control of the disease or survival of all
patients with diagnosed breast cancer. Only one study has
evaluated such outcomes, and although MRI appears to
reduce the incidence of local recurrence (1.2% vs. 6.8%),
confounding differences in tumor characteristics between
patients treated with and without MRI did occur [51].
The British COMICE trial is a large multicenter trial that
randomizes patients between MRI and no-MRI and
evaluates the quality of preoperative staging, the differ-
ences in outcome, differences in quality of life and cost-
effectiveness [52]; the first results are expected in 2008.
This study and similar ongoing studies may provide better
evaluation of staging in the near future.
Synchronous bilateral breast cancer is reported in about
2–3% of all breast cancer patients [53–55], but it is
probably more common. Synchronous contralateral lesions
are occult on mammography in about 75% of cases. MRI
detects otherwise occult lesions in 3–5% of patients that
undergo preoperative MRI [56–58]. Some studies show
even more alarming results and report MRI-only detected
contralateral breast cancer in 19% [59] and 24% [60].
These lesions would probably have presented as meta-
chronous contralateral carcinomas without MRI, as is also
clear from the above-mentioned outcome study. The rate of
contralateral carcinomas detected at follow-up decreased
from 4% without MRI to 1.7% with MRI [51].
Screening of the contralateral breast in patients with
proven unilateral breast cancer is thus a valid indication for
the performance of preoperative breast MRI. In practice
this means that preoperative MRI is recommended in all
patients with histologically proven breast cancer, even
though the indication for ipsilateral staging of the cancer is
still under investigation.
Especially in the case of dense breasts, MRI is recom-
mended preoperatively. Furthermore, in patients with histol-
ogic evidence of invasive lobular carcinoma, a preoperative
MRI is strongly recommended as these tumors show a
more permeative growth pattern and, consequently, are
more difficult to measure [32, 61], are more often
multifocal or multicentric (additional foci in 32%) [62,
63] and are more often complicated by concurrent
contralateral carcinomas (occult tumors detected in 7%)
[62, 64, 65].
Unknown primary
In the case of a carcinoma of unknown primary, metastases
are diagnosed, but a primary tumor site cannot be
identified. These metastases may either present in the
axillary lymph nodes, the supraclavicular lymph nodes, the
bones, the liver, the brain or the lungs.
When the mammogram does not show any abnormality,
reports in the literature show, in about 50% of the cases, an
abnormal MRI [66]. In case of metastatic axillary lymph
nodes, MRI is even able to detect a primary breast tumor in
75–85% of patients [67, 68]. MRI thus can subsequently be
used to plan the most appropriate treatment as the size of
these lesions on MRI is usually concordant with the size at
pathology, thus MRI may prevent unnecessary mastec-
tomies or assign patients with large tumors to neoadjuvant
protocols.
The evaluation of therapy response in the neoadjuvant
chemotherapy setting
Neoadjuvant chemotherapy is the administration of che-
motherapy prior to surgical treatment of cancer. Its
principal indication is the treatment of unresectable breast
cancers, and its goal in this setting is to reduce the tumor to
a size that allows resection. However, many studies have
shown that the prognosis of breast cancer is equal when
chemotherapy precedes or follows after surgery. Because

there are some theoretical benefits in the neoadjuvant
setting, and tumor response can be closely evaluated with
the tumor in situ, neoadjuvant chemotherapy is also the
standard of care in large T2 and T3 tumors. MRI has been
shown to be superior to evaluate tumor response to
neoadjuvant chemotherapy compared to clinical examina-
tion, mammography or ultrasound and is thus the imaging
investigation of choice.
If neoadjuvant chemotherapy is given to a patient, the
first breast MRI should be performed before the start of
chemotherapy. A second MRI, for the evaluation of the
effect of chemotherapy on the tumor, should be performed
when approximately half of the course of chemotherapy
has been administered. A third MRI investigation should
be performed after the final course of chemotherapy to
evaluate the residual disease. In most hospitals four to six
cycles of chemotherapy are given in the neoadjuvant
setting.
Response is normally measured using the RECIST
criteria [69]. Using these, complete response (CR) is
defined as complete vanishing of the tumor, partial
response (PR) is defined as decrease of the sum of the
longest axes of all individual lesions by more than 30%,
progressive disease (PD) is defined as an increase of this
sum by more than 25% and the remainder is classified as
stable disease (SD). Response to chemotherapy is espe-
cially well evaluated in the non-responders (SD, PD) and
the good-responder group (CR). The effect of the chemo-
therapy in partial responders is less well established.
Several studies compared the ability of clinical exam-
ination, mammography, ultrasound and MRI in the
assessment of final response [70–80]. They showed that
MRI measurement after therapy correlated best with the
pathological findings and was the best technique for
assessing response.
Nevertheless, MRI is unable to detect small residual
tumor foci that may persist after neoadjuvant chemother-
apy. Radiological complete response is thus no proof for
pathological complete response (pCR); therefore, resection
of the initial tumor bed is still essential in the treatment of
these patients [77, 79].
Observation of response during treatment is important as
this is the only measure that justifies the applied chemo-
therapeutic regimen and is the only response evaluation
that allows a change in this regime before its completion.
Currently, the performance of MRI halfway during treat-
ment may only change the treatment in clear non-
responders and those with progressive disease as there
are no other criteria for early response evaluation. This is
due to the fact that size of the tumor often does not
immediately decrease. Therefore, the performance of MRI
earlier in the treatment (e.g., after the first cycle) as is under
investigation in several large trials (such as the ACRIN
6657 trial) is currently not recommended, although in one
study complete responders had a change in diameter of at
least 45% after the first course of chemotherapy [72]. In
1311
another study early change in volume was the most
predictive of final response [75]. The value of these MRI
investigations first should be established, and criteria for
early response need to be defined.
Several other techniques, such as MR spectroscopy [81],
diffusion imaging [82] and FDG-PET [83–85] show
promise in the (early) evaluation of tumor response to
therapy. However, none of these techniques have been
tested in large-scale prospective studies and can thus not
(yet) be recommended for clinical practice. For a more
detailed description of the studies so far performed in the
evaluation of response to neoadjuvant chemotherapy, we
refer to the review by Tardivon et al. [86].
Imaging of the breast after conservative therapy
MRI may be considered after breast-conserving therapy
(BCT) in three instances: first as an evaluation tool for
residual disease after positive tumor margins, second as a
method of evaluating suspected recurrence by either
clinical examination, mammography or ultrasound and
third as a screening tool in all patients who undergo BCT.
Unfortunately, early postoperative MRI is hampered by
strongly enhancing resection margins in response to the
surgical intervention. Therefore, MRI is unable to exclude
residual tumor at the biopsy cavity sufficiently, and hence
does not change the surgical approach consisting in a larger
resection of the tumor bed in the direction where patho-
logical analysis of the surgical specimen showed positive
margins [87–89].
Although preoperative staging MRI is to be preferred
over MRI after initial surgery, it can be performed when
surgical margins are badly involved. In such cases, the first
acceptable MRI results are not to be expected sooner than a
month after surgery [90]. However, as MRI may reveal more
widespread disease throughout the breast remote from the
lumpectomy site, it can provide valuable information
concerning the decision of wider excision versus mastectomy
[91–93]. Morakkabati et al. have shown that postradiation
changes occur during and up to 3 months after radiation
therapy, but do not reduce the accuracy of MRI to identify
residual or recurrent tumor compared to patients without
radiation therapy [94].
Most local recurrences after BCT and radiotherapy occur
within 5 years after the initial surgery, and the annual risk is
estimated at 1–2% per year [95–98]. Early detection and
treatment of recurrent disease are important as it may still
present without distant metastases. Second primary ipsi-
lateral carcinomas in the treated breast can occur at every
site and develop on average 7 years after the first primary
tumor [99]. The sensitivity of mammography for recurrent
disease in the treated breast is limited, but breast MRI can
be a valuable complementary tool as explained earlier.
A local recurrence on MRI has the same appearance as a
new primary malignancy with strong early enhancement,
1312
while a fibrous scar shows either no enhancement or very
slow enhancement. In a treated breast, the specificity of
breast MRI is higher than in an untreated breast.
Different studies have shown that MRI is the most
sensitive technique in detecting a local recurrence of the
disease [36, 100–104]. When a local recurrence is suspected
upon clinical findings or abnormalities on mammography or
ultrasound, MRI can be used to exclude local recurrence
with a high negative predictive value and thus prevent
unnecessary biopsies [93, 103, 104].
Analogous to the situation in preoperative staging, MRI
is able to detect multifocality and multicentricity unnoticed
by conventional imaging. Naturally, in these cases, the
evaluation of the contralateral breast is also important.
There is currently not sufficient evidence to recommend
or not the screening of patients treated by BCT with MRI.
So far, only one small trial has been performed [101],
which showed no difference in sensitivity for recurrence
between clinical examination combined with mammogra-
phy and MRI alone. However, the specificity of MRI was
much higher (93% vs. 67%), confirming its value as
additional investigation. Moreover, in some patients, it can
be impossible to image the primary tumor region by
mammography after conservative therapy [105]. In these
cases breast MRI is mandatory.
The risk of local recurrence is strongly dependent on the
age of the patient at the time of diagnosis [106–109].
Patients over 50 have a risk of approximately 4% after
5 years, but this risk is estimated at 12% after 5 years for
patients who were under 45 years of age [108] and at 20%
after 5 years for patients under 40 [106]. Although
additional boost radiotherapy to the tumor bed can reduce
this risk to 10% at 5 years, these patients have a lifetime
risk that is probably still greater than 20%, which is equal
to the lifetime risk demanded for MRI screening in the
general population, as described below.
Therefore, annual MRI screening is an option for all
patients under 50 at the time of diagnosis of the first primary
carcinoma, but this should first be investigated in larger trials.
MRI screening
The high sensitivity for cancer makes breast MRI a
desirable technique for screening purposes. Therefore,
many countries have performed screening studies in high-
risk populations. The American Cancer Society (ACS) has
recently issued guidelines for the performance of MR
screening based upon the analysis of six of these studies
[110]. As the most important of these studies were all
performed in Europe (e.g. the Dutch MRISC study [111],
The UK-based MARIBS study [112], the German single-
center study [113] and the Italian HIBCRIT study [114]),
the ACS recommendations apply mostly to the European
situation. The overall sensitivity for breast cancer in these
high-risk populations is between 71 and 100% for MRI
compared to 16–40% for mammography. The specificity
ranges from 81 to 99% for MRI and 93 to 99% for
mammography, which is illustrative for the higher detec-
tion rate of MR and the (almost two times) higher recall
rate that unfortunately complicates MR screening.
There is evidence for the value of annual MR screening in
BRCA gene mutation carriers, their first degree, untested
relatives and all women with a lifetime risk of 20–25%
according to models that depend largely upon family history.
Furthermore, MRI screening is advised in patients who
received radiation to the chest in their 2nd or 3rd decade
(mostly patients with a history of lymphoma) and patients
with inherited syndromes, such as LiFraumeni and Cowden
syndrome, and their first-degree relatives, although there is
no direct evidence for these latter recommendations.
Currently there is not sufficient evidence to recommend
MRI or not in women with a lifetimerisk of 15–20%,
those with high-risk lesions (LCIS, ALH, ADH) and those
with heterogeneously or extremely dense breasts on
mammography.
Women with a lifetime risk of less than 15% should
currently not be enrolled in MR screening programs.
It is still unclear when to start screening. In most high-
risk patients, starting at the age of 30 will probably be
sufficient. However, in families where the first carcinomas
presented at younger ages, the screening needs to start
earlier as well. It seems advisable to follow the guidelines
for mammography in this aspect and start screening at an
age 5 years younger than the youngest relative that
presented with cancer. It is also unclear for how long
screening with MR should be continued; in older women
the breast density decreases significantly, and the added
value of MR might thus decrease. However, at every age,
the sensitivity for breast cancer of MRI is higher than that
of mammography.
Prosthesis imaging
The evaluation of breast implants, which are either placed for
breast augmentation or for breast reconstruction after surgery
for breast cancer, can be done with MR. This demands
specific sequences that are aimed at the visualization of
silicone and provide concurrent suppression of the water
signal [115–117]. By using these sequences and specific
evaluation criteria [116, 117], MRI is the most accurate
modality in the evaluation of implant integrity. Its sensitivity
for rupture is between 80 and 90%, and its specificity is
approximately 90% [117–119], whereas the sensitivity of
mammography is approximately 25% [120, 121].
Nevertheless, the indication for breast MRI is less clear
than might be expected. Ten years after insertion,
approximately 50% of all breast implants are ruptured
[117, 118]. It seems therefore advisable to use breast MR
only when there are specific complaints that might be
caused by leaking prostheses (e.g., local inflammation or
 1313

the formation of silicone granulomas). MRI may then be For adequate performance, some important points
used to exclude a ruptured prosthesis as the underlying should be kept in mind.
cause of the complaints, and it may also aid explantation
– A dedicated bilateral breast coil is mandatory.
surgery as it documents the presence and extent of silicone
– The spatial and temporal resolution must be sufficient.
leakage better than any other imaging modality.
– A T1-weighted sequence should be obtained for at least
In patients with prosthesis and prior breast cancer, MRI
three time points, one prior to and two after contrast
may be used to evaluate suspected recurrent disease or as a
administration.
postoperative screening modality. The presence of the
– Reporting should be performed by a radiologist with
implant does not seem to decrease the sensitivity of breast
experience in breast MRI, using the ACR BI-RADS
MR [122, 123].
MRI Lexicon.
– MRI-guided breast biopsy must be available.
MR-guided biopsy and lesion localization The most important indications currently present are
listed below.
It is clear that the increasing list of indications for the
– Problem solving in case of inconclusive findings on
performance of breast MR leads to the detection of many
conventional imaging.
lesions that are neither palpable nor visible on conventional
– Screening of the contralateral breast in women with
imaging techniques. Although most MR-detected lesions
histological evidence of unilateral breast cancer.
can be found (and biopsied) at second-look ultrasound,
– Evaluation of the breasts in case of metastases of an
many can not. This stresses the importance of the
unknown primary carcinoma.
possibility of performing MR-guided biopsies and locali-
– Evaluation of therapy response in patients treated with
zations. Any site that performs breast MR examinations
neoadjuvant chemotherapy.
should either be able to perform MR-guided interventions
– Exclusion of local recurrence after breast-conserving
in the breast or should be in close contact with a site that
therapy.
can perform these investigations for them.
– Screening of women with a lifetime risk of 20% or
However, the exact description of the involved tech-
more to develop breast cancer, including mutation
niques and the minimal requirements that need to be met
carriers.
when performing these interventions are quite extensive
and cannot be described in this paper. A separate guideline
describing these interventions will be published soon by
Heywang-Kobrunner et al.

Conclusion
Breast MRI is no longer an experimental modality, but has
attained a solid position in the diagnosis and workup of
(suspected) breast lesions.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and reproduction
in any medium, provided the original author(s) and source are
credited.

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